Provider Demographics
NPI:1225860224
Name:LILLEY, KADIJAH A
Entity type:Individual
Prefix:
First Name:KADIJAH
Middle Name:A
Last Name:LILLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3851 DUNHAGAN RD STE 102
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-6640
Mailing Address - Country:US
Mailing Address - Phone:252-751-0518
Mailing Address - Fax:
Practice Address - Street 1:1118 GRECADE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-8725
Practice Address - Country:US
Practice Address - Phone:252-751-0518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-17
Last Update Date:2024-11-06
Deactivation Date:2024-10-23
Deactivation Code:
Reactivation Date:2024-11-06
Provider Licenses
StateLicense IDTaxonomies
NCRBT-24-337143106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician